Remark code M104 indicates that the documentation provided has justified a discontinuation in the patient's therapy. Consequently, a new period for capped rental will commence from the date the equipment is delivered. Additionally, the payment amount for this item or service has reached the upper limit as per the established fee schedule.
Common causes of code M104 are typically related to situations where there has been an interruption in the rental period of durable medical equipment (DME). These interruptions can occur due to various reasons, such as:
- The patient no longer needed the equipment for a period of time, which led to the cessation of billing for the rental.
- The patient was admitted to a facility where the rental of the equipment was not billable (e.g., a hospital) and upon discharge, the patient requires the equipment again.
- The equipment was returned because it was defective, not suitable for the patient's needs, or the patient chose to discontinue use, and after a break, a new piece of equipment is provided.
- The patient switched providers for their equipment rental, and the new provider is starting a new rental period.
- There was a lapse in the physician's order or medical necessity documentation, resulting in a temporary halt of the rental claim submissions, which now requires a new rental period upon resumption.
Ways to mitigate code M104 include ensuring that the documentation accurately reflects the medical necessity for a break in therapy and that the break is appropriately justified according to the patient's condition and treatment plan. It's important to keep detailed records of the patient's use of the equipment, including dates and reasons for any interruptions in use. Before submitting claims, verify that the rental period aligns with the equipment delivery dates and that the claim reflects the start of a new rental period if applicable. Regularly review the fee schedule to ensure that the charges do not exceed the maximum approved amount for the item or service provided. Additionally, staff training on proper documentation and billing practices for capped rental items can help prevent this code from occurring.
The steps to address code M104 involve several key actions to ensure proper billing and reimbursement for the new capped rental period. Firstly, confirm the accuracy of the information provided that indicates a break in therapy. This may involve reviewing patient records, therapy dates, and previous claims.
Next, update the billing system to reflect the start of a new capped rental period beginning with the delivery date of the equipment. Ensure that the claim includes all necessary documentation to support the initiation of a new rental period.
Additionally, verify that the charges for the equipment or service are in line with the maximum approved amounts under the current fee schedule. If the charges exceed the approved amount, adjust the billing to comply with the fee schedule limits.
It's also important to communicate with the patient or their representative to explain the new rental period and any potential financial responsibilities they may have.
Finally, resubmit the claim with the corrected information and any required documentation to support the new capped rental period. Monitor the claim to ensure it is processed correctly and follow up with the payer if there are any further issues or denials related to the new rental period.